Massey, Wood and West, Inc.

Fueling Richmond with prompt dependable service since 1923.

New Account Form
New Account Application

To establish a new account, fill out the form below or call the Credit Department at 804-355-1721.

Type of Account Requested:


First Name:

Last Name:

Social Security Number Required for 30 day accounts:

Home Address:

Home Phone Number:

Length of time there:

Own or Rent:


Employer Address:

Employer Phone Number:

Nearest Relative (not living with you):



Nearest Relative (not living with you) Address:

Nearest Relative (not living with you) Phone Number:

If joint account check here and fill out joint account info. 

Joint Account

Co-Applicant First Name:

Co-Applicant Last Name:

Co-Applicant Social Security Number:

Co-Applicant Employer:

Co-Applicant Employer Address:

Co-Applicant Employer Phone Number:

Bank Information Checking Account:

Bank Information Savings Account:




Product Information

Previous Supplier:

Product Type:

Tank Size:

Above Ground or Underground Tank:

Automatic Delivery or Will Call:

Credit Agreement:

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